Now Viewing: Quality of care

ACOG Issues New Guidelines to Curb Overuse of C-Sections

Feb 27, 2014, 5:27 PM, Posted by Tara Oakman

Tara Oakman Tara Oakman

While I knew that having children would turn my world upside down, I assumed that this transition would be more metaphorical than literal. Ha! Moments before I was discharged from a Maryland hospital a few days after my twins were delivered by c-section, the ground shook violently. My husband had just left the hospital room to get the car, so I was alone with two newborns and a painful surgical wound. All I could think was ... “This is an earthquake! I have two babies. And I can’t move!

One of the scariest parts of the experience was that I couldn’t respond to my maternal instinct to quickly pick up and protect my babies because I had just had major abdominal surgery. Granted, managing in an earthquake is not a common part of recovery from a C-section, but there can be many other dangerous complications that occur more frequently, such as infection, emergency hysterectomy or heavy blood loss. It can also lead to greater difficulty with breastfeeding. C-sections are also very costly, even if there are no major complications. They are much more expensive than vaginal delivery.

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Aligning Measures to Improve Quality

Feb 11, 2014, 4:51 PM, Posted by Gerry Shea

Doctors go over a patient's charts in the emergency room.

The quest over the last decade and a half to define and quantify “quality” in health care in the United States has resulted in widespread use of quality measures. Unfortunately, the alignment of these measures among entities in both the private and public sectors has been secondary to the efforts to identify and use good measures. This failure has resulted in a tremendous lack of comparability between quality improvement efforts.

While not surprising, the near total lack of alignment has become a major obstacle in the effort to improve care for patients. It leads to significant burdens for those looking to improve, wastes valuable (and finite) resources and is a drag on overall quality improvement efforts. Additionally, it creates a considerable barrier to efforts encouraging value-based decision making by consumers and others.

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On the Way to Better Health, a Call to Educate the Consumer With Complete and Useful Information

Jan 24, 2014, 2:41 PM, Posted by Tara Oakman

“An educated consumer is our best customer...”

A big sign with these words welcomed me and others into the local department store, Syms. I’m definitely not the only one who noticed. In fact, an educated consumer of this blog would know that it resonated with Susan Dentzer as well.

As a child, this statement baffled me. On the plus side, pondering its meaning gave me something to do during seemingly interminable shopping expeditions with my parents. Why, I wondered, does a department store care about how much consumers know? Don’t they just want them to buy clothes?

Now I get it.

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Five Takeaways from the National Transparency Summit: An Issue Whose Time Has Come

Dec 9, 2013, 4:33 PM, Posted by Susan Dentzer

Susan Dentzer RWJF Senior Health Policy Adviser Susan Dentzer
  1. Transparency is an idea whose time has come—in large part because U.S. consumers are feeling so much pain from higher health costs. Health economists have long noted that U.S. health care prices are out of whack and that hospital chargemasters are nonsensical. Recent media coverage of these phenomena has captured widespread attention, perhaps because consumers are being hit so hard in the pocketbook. Since 2000, rising prices of hospital charges, professional services, drugs, devices and administrative costs, are responsible for 91 percent of the increases in health spending. Meanwhile, consumers’ out-of-pocket spending on health care, estimated at $329 billion this year, is projected to rise to $411 billion in 2020—a 25 percent increase. Almost three in five workers in small firms, and one in three workers in larger firms, are in a health plan with a deductible of at least $1,000 for single coverage, and in 2012, nearly one of five U.S. adults was contacted by a collection agency over unpaid medical bills.

    It’s well established that much of this money is being spent on health care of questionable value. With so much of their money—and their well-being—now at stake, “People are going to impose transparency on the health care industry,” predicted Leah Binder, a conference participant who heads the Leapfrog Group.

  2. Consumers and patients deserve to know far more about the costs and quality of care, but unless the two are linked, the public may continue with its longstanding delusion that the more expensive the care, the better the quality. Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, noted that this widespread consumer misapprehension constitutes a “perverse incentive” for providers to continue to raise prices. Meanwhile, evidence of poor quality abounds. Martin Makary, a Johns Hopkins University physician and author of Unaccountable: What Hospitals Won’t Tell You And How Transparency Can Revolutionize Health Care, reminded the conference that preventable adverse events in hospitals are now the nation’s third leading cause of death annually. Many highly esteemed medical centers that end up routinely on “best hospital” lists don’t make the Joint Commission’s tally of top performers on basic quality and safety measures.

    Conference speakers agreed that there’s a pronounced need to combat these trends by developing more and better quality measures—especially those capturing care outcomes, and in particular, the outcomes that are most important to patients. Providers’ scores on these measures should then be funneled to purchasers and the public. “When consumers can really start to see that this hospital is better than this other hospital, or this doctor is better than that doctor, they will start to move,” said Bill Kramer, executive director for national health Policy at the Pacific Business Group on Health.

    Promising prototypes of the platforms that could communicate such information include winners of the RWJF Hospital Price Transparency Challenge—for example, Consumer Reports’ Hospital Adviser: Hip & Knee, which combines hospital quality rankings with Medicare cost data to help consumers pinpoint high value institutions where they could obtain surgery.

  3. Fostering greater transparency will be a long process, but there could be relatively quick “wins.” Many contracts between health insurers and providers contain “gag clauses” that bar both parties from disclosing claims data or prices paid for care. The clauses appear to serve both parties’ interests—helping to protect health plans’ proprietary interests in the provider networks they’ve established, and providers’ desire not to disclose how little they are willing to be paid. California has outlawed such clauses in health plan contracts, and many conference attendees agreed that other states should follow suit.

    What’s more, a total of 16 states have set up mandatory or voluntary all-payer claims data bases (APCDs) to pool statewide data on diagnoses, procedures, care locations, and provider payments. Conference participants agreed that more states should enact mandatory APCD’s, or use the regulatory authority in state insurance laws to compel insurers to issue payment and pricing data, as was done in Rhode Island.   More states could also follow the lead of Maine Quality Counts, the private, independent nonprofit organization that leads the RWJF-sponsored Aligning Forces for Quality coalition in the state, and which has aggregated health plan data for purchasers, consumers and providers to promote transparency on quality and cost.

  4. Transparency in the hands of consumers could be powerful—but in the hands of providers, even more so. Health care providers themselves often lack information about the quality and costs of their care. In particular, transparency can focus attention on the extreme amount of variation among providers in the care they provide. Glenn Steele, president and CEO of Geisinger Health System, described how Geisinger’s physicians came together to define “best practices” across a dozen hospital episodes of care, including heart bypasses, hip replacements, and gastric bypass surgery. As physicians in the system adhered to these guidelines, spending fell, by 20 percent  because doctors narrowed the indications for which they agreed that the procedures were warranted, and 15 percent by reducing unnecessary variation.
  5. Transparency is a necessary but insufficient tool for health system transformation. Openness about price and quality alone is “not going to be enough” to achieve the goals of the Triple Aim, observed Steven Brill, whose Time magazine article in March 2013 gave renewed focus to the issue. Payment reforms and “culture change” that shift providers from a volume-based to-value-based approaches remain critical. What’s more, consumers need to have health insurance benefit designs beyond high-deductible health plans that encourage them to make wise choices, such as “value-based” benefits” that help nudge them toward cost-effective care delivered by low-cost, high quality providers. Others at the conference warned that regulators must stay attuned to unintended consequences of health system transformation, such as the consolidation of health care providers that could lead to attempts to jack up prices.

    In the end, “We don’t win the game until the care gets better,” observed Jay Want, CEO of WantHealthcare. The nation also must ensure “that the transparency we seek will serve to change the way we think about health and wellness,” said RWJF president and CEO Risa Lavizzo-Mourey. “We need to use our skills, our imagination, our influence, and, yes, our hearts, to transform our nation into one that considers being healthy part of what it means to be an American.”

    To that end, transparency about the choices we face as a nation on the costs and quality of health and health care can give our society a critical lens to look within.

“An Educated Consumer is Our Best Customer:” Four Things to Know About Transparency In Health Care Prices, Costs and Quality

Nov 26, 2013, 10:14 AM, Posted by Susan Dentzer

Watch our December 6, 2013, FirstFriday Google+ Hangout archive on transparency in health care.

Panic about high health insurance premiums. Fears about high-cost health-care providers being cut out of health plan networks. Worries that the health plans now available through health insurance exchanges won’t cover the care that patients need.

Welcome to the rollout of Obamacare....right?

Actually, with the exception of the new health insurance exchanges, all of the phenomena described above have a long history. Similar concerns were voiced loudly in the late 1980s and 1990s, when “managed care” in health insurance became a dominant force on the health care and health insurance landscape.

What’s amazing to people who lived through both of these eras—then and now—is how little has changed.  

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Don't Believe Everything You Read

Aug 2, 2013, 12:22 PM, Posted by Pam S. Dickson

Close up of a mans hand in surgery

Does anybody commute to work anymore without passing by a huge billboard promoting world-class health care at a nearby hospital or surgicenter?  I know I see enough of them to have become pretty calloused to their messages.  But then, I don’t need health care right now.

What if I did?  Could I count on these extravagant advertisements to give me good guidance about where to seek care?

Unfortunately, the answer is probably not.

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U.S. Women: Many Missing From the Picture of Health

Jun 4, 2013, 4:21 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

The missing women. The concept was first put forward by Nobel Prize-winning economist Amartya Sen in the 1980s. He pointed to demographic evidence that hundreds of millions of women were simply missing from the planet—most likely never having been born, or died, due to discrimination or neglect.

Biologically, females are stronger than males; as a result, in much of the world women outnumber men in population sex ratios. But Sen found the ratio was flipped in India, Pakistan, and Bangladesh. Subsequent investigations show a similar pattern in other parts of the world where women are at substantial economic and social disadvantage to men—including other countries in Asia, the Middle East, North Africa, and central and Eastern Europe.

Now, research sponsored in part by the Robert Wood Johnson Foundation raises the question: Is there a growing corps of “missing women” in the United States as well?

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To End Readmissions, Look to a Wired Community

May 30, 2013, 1:14 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

What does it take to keep the sick and elderly from spinning through the revolving doors of the nation’s hospitals? Answer: A village.

Although avoiding unnecessary hospital readmissions is typically framed as an issue for hospitals, it’s more accurately seen as an issue for entire communities. One in five Medicare beneficiaries now end up back in the hospital within 30 days of discharge, at an estimated cost of more than $17 billion annually. It will take local health care communities working together to keep more of those patients at home, or at the very least, in a less acute care site.

A recent report from the Robert Wood Johnson Foundation, The Revolving Door: A Report on US Hospital Readmissions, profiles cases that make the point.

  • Eric was discharged from the hospital after being treated for chronic obstructive pulmonary disease, yet he didn’t fully understand how to use his inhaler and continued to smoke. He soon ended up back in the hospital. Whose responsibility was it to make sure that the cycle didn’t repeat itself? As it happened, his health plan eventually flagged him as at risk for readmission and he received regular follow-up care, such as smoking cessation classes, and having to answer five questions a day from his care team so they could monitor his breathing. 
  • Barbara, who has type 2 diabetes, was hospitalized with her blood sugar out of control, and then discharged without understanding how to administer her insulin properly or maintain an appropriate diet. Like Eric, she was one of the 50 percent of newly discharged Medicare patients who don’t see a primary care clinician or specialist within two weeks of leaving the hospital. Whose job was it to get her that appointment? It took a trip back to the hospital before she met with a dietitian and learned how to administer and adjust her insulin.

To crack down on avoidable readmissions, Medicare began penalizing hospitals last year if patients with three conditions—pneumonia, congestive heart failure, and heart attack—were readmitted within 30 days at rates above certain thresholds. At least two other federally sponsored efforts, the Partnership for Patients and the Community-Based Care Transition Program have also worked over the past several years to reduce avoidable readmission rates. A third, the Beacon Community Cooperative Agreement program, is now shedding a bright light on how communities can best use information technology in the process.

The Beacon program was part of 2009 federal legislation aimed at boosting adoption of electronic health records (EHRs) and other health information technology. Seventeen communities won three-year grants totaling  $250 million to use EHRs, and exchange of digital information among health care providers, to improve health and health care. Three of the communities—Cincinnati, Detroit and Western New York—are closely linked to the RWJF’s Aligning Forces for Quality efforts in those same communities.  

One tool that Beacon has tested is electronic alerts that originate in a hospital’s information system when patients undergo a change in status—for example, when they are admitted to the hospital, discharged, or transferred to another facility such as a nursing home. If the community has a health information exchange system, the message is processed and turned into an ADT alert, then sent to a primary care doctor or care manager. These professionals can then step in to smooth the transition and make certain that chronically ill patients get the attention they need.

Use of ADT alerts has been shown to deter unnecessary visits to the emergency room and initial as well as repeat hospitalizations. But communities must do a lot of hard work, together, to put them in place. They have to forge agreements with technology vendors, adopt data use agreements among providers, and undertake measures to protect patients’ privacy.  What’s more, primary care physicians usually have to adapt the way they practice medicine, becoming far more proactive rather than reactive.

Fortunately, even as the Beacon program draws to a close in September, the 17 communities have banded together as the “Beacon Nation” to share the lessons they’ve learned with others. The group recently released the first of eight learning guides, this one to help communities improve care transitions using the ADT alerts. (Full disclosure: Along with my foundation colleague Michael Painter, I serve as one of 14 unpaid members of an advisory committee to the Beacon Nation group.)

Following the steps in the learning guide isn’t simple, but the take-home message is, says Farzad Mostashari, head of the Office of the National Coordinator of Health Information Technology, which oversees the Beacon program. “What the guide teaches us is that it’s not all about the technology,” he says. “Incorporating the technology with the people [in the community]—that’s the lesson.”

In other words, welcome to today’s high-tech health care villages—where lots of dedicated people and communities are coming together to achieve the Triple Aim.